Asthma is extremely costly, adding nearly 50 cents to every health care dollar spent on children with the condition.

In 2006, the United States spent eight billion dollars alone on treating childhood asthma. Also, asthma was associated with 13.6 percent of all pediatric hospitalizations and children with asthma who use emergency department care are significantly more likely than children without asthma to require inpatient admission (65 percent versus 44 percent). There are widespread racial and ethnic disparities regarding access to effective treatment. . In the United States, the burden of asthma falls disproportionately on Black and Hispanic largely Puerto Rican populations. These groups have high rates of poor asthma outcomes, including hospitalizations and deaths. This burden has environmental, socioeconomic, and behavioral causes. As much as 40 percent of the risk of asthma in minority children is attributable to exposure to residential allergens that could be reduced, if not eliminated. African-American children and Hispanic children, receive about half as much outpatient care and medication management than White children. Because they are more likely to be low-income and medically underserved, Hispanic children also experience the highest hospital emergency department expenditure rate. Asthma is a chronic condition with acute exacerbation. Therefore, it is imperative to provide continuous care in order to control symptoms, prevent exacerbation, and reduce chronic airway inflammation. Asthma is extremely costly. Asthma adds nearly 50 cents to every health care dollar spent on children compared to children without asthma. In 2006, the nation spent eight billion dollars alone on treating childhood asthma. Compared with children who do not have asthma, pharmaceutical expenditures are nearly four times higher for asthmatic children, outpatient office-based expenditures are 55 percent higher, and emergency department care is 40 percent higher. Asthma was associated with 13.6 percent of all pediatric hospitalizations in 2006, and children with asthma who use emergency department care are significantly more likely than children without asthma to require inpatient admission (65 percent v 44 percent). Racial and ethnic disparities in access to effective treatment are widespread. Despite the need and risk, health care expenditures are the lowest for the children most at risk. African-American children and Hispanic children receive about half as much outpatient care and medication management than white children. Yet because they are more likely to be low income and medically underserved, Hispanic children also experience the highest hospital emergency department expenditure rate. Insurance is key, but we may be missing many children. Current evidence suggests that Puerto Ricans have a higher prevalence than other ethnic groups, including other Hispanic groups. Island and mainland Puerto Rican children have the highest rates of asthma and asthma morbidity of any ethnic group in the United States. Mainland and island Puerto Rican children have the highest rates of asthma of any ethnic group and are more likely to die because of their asthma compared with other children. Presently numerous studies have been implicated in explaining there higher rates of asthma and morbidity among minority children, yet the factors accounting for this disparity are not understood. Presently, poor adherence and inadequate overall asthma management, service utilization, poor quality of life, and even asthma deaths in children.

A specific example of how a state/territory level policy is translating into poor health outcomes is evidenced by a recently published study by Vila et al. This study established a correlation between under treatment of pediatric asthma with provider reluctance of prescribing certain long-term medication. A possible reason for under treatment may be due to the fact that when a patient requires further treatment the referring or prescribing physicians absorbs the related costs. The costs of the medication being prescribed are deducted from the capitated amount already given by the Puerto Rican Public Health Plan to physicians. This study compared children enrolled in the publicly managed program versus Puerto Rican children enrolled in the islands privately managed care programs. This finding has also been substantiated from survey data provided by physicians, regarding drug policy provider responses to drug payment policy in the United States. The data suggests that providers are more likely to prescribe medications when it does not implicate a financial risk for that prescribing physician. Literature indicates that there is discrepancy in healthcare reimbursement between public and private payers in Puerto Rico. The literature has often led researchers to believe that this frequency of long-term control medication to low-income children with public insurance is lower compared to ones on private because the insurance follows the patient. Therefore, this may be the reason why there is observed health disparity in the use of asthma control medications as measured by emergency department use and hospitalization. When payment policies between the private and public health care sectors differ they could possibly explain differences in medication dispensing and health care utilization among children with asthma enrolled in the Puerto Rican Public Health Plan as compared to children enrolled in private insurance plans. Some reason may be due to reluctance physicians take on patients carrying the public health plan due to knowing the lower reimbursement schedule went which is then a barrier good heath care access. The current health policy makes it difficult for providers to deliver high quality care due to having to enroll many patients into order maintain a minimum net income. Specifically, this policy needs to be revised so that primary care providers do not feel hesitant to prescribe long-term medications to patients with persistent asthma, or to refer patients who require subspecialty care to specialists. Government of Puerto Rico along with Department of Health needs to focus on strategies to share costs within the territory, or revisit the low capitation rates. A specific example of how a state/territory level policy is translating into poor health outcomes is evidenced by a recently published study by Vila et al. This study established a correlation between under treatment of pediatric asthma with provider reluctance of prescribing certain long-term medication. A possible reason for under treatment may be due to the fact that when a patient requires further treatment the referring or prescribing physicians absorbs the related costs. The costs of the medication being prescribed are deducted from the capitated amount already given by the Puerto Rican Public Health Plan to physicians. This study compared children enrolled in the publicly managed program versus Puerto Rican children enrolled in the islands privately managed care programs. This finding has also been substantiated from survey data provided by physicians, regarding drug policy provider responses to drug payment policy

in the United States. The data suggests that providers are more likely to prescribe medications when it does not implicate a financial risk for that prescribing physician. Literature indicates that there is discrepancy in healthcare reimbursement between public and private payers in Puerto Rico. The literature has often led researchers to believe that this frequency of long-term control medication to low-income children with public insurance is lower compared to ones on private because the insurance follows the patient. Therefore, this may be the reason why there is observed health disparity in the use of asthma control medications as measured by emergency department use and hospitalization. When payment policies between the private and public health care sectors differ they could possibly explain differences in medication dispensing and health care utilization among children with asthma enrolled in the Puerto Rican Public Health Plan as compared to children enrolled in private insurance plans. Some reason may be due to reluctance physicians take on patients carrying the public health plan due to knowing the lower reimbursement schedule went which is then a barrier good heath care access. The current health policy makes it difficult for providers to deliver high quality care due to having to enroll many patients into order maintain a minimum net income. Specifically, this policy needs to be revised so that primary care providers do not feel hesitant to prescribe long-term medications to patients with persistent asthma, or to refer patients who require subspecialty care to specialists. Government of Puerto Rico along with Department of Health needs to focus on strategies to share costs within the territory, or revisit the low capitation rates. Emphasis on Provider training is also essential if more children are to be properly medicated. Research on physician education initiatives show benefits when measuring follow-up care, patient education, these good practices were implemented due to trainings provided to physicians. Provider groups who have received training implement changes in their practices would result in improved disease control for their patients. With a better health care reimbursement system health care providers could be more aggressive in ensuring that Puerto Rican children receive appropriate asthma treatment, follow-up care, and education about asthma triggers and prevention strategies. Underuse of preventive anti-inflammatory medications was reported in studies of mostly Puerto Rican populations. Physicians need to be compensated for their time in order to provide good continuous care.

f. Need for Change in the Puerto Rican Public Health Plan Policy The need for leadership will call for a revision of the reforma form of healthcare in Puerto Rico. In 1995, Puerto Rico underwent a change in its health policy, transforming the delivery health care system into a managed care system, which is equivalent to Medicaid Program on the mainland. This model has increased access to care by providing a wider net of providers to the medically indigent. But because it has in place a capitated system of payment, any medications and specialists come out of primary care providers capitation, the system discourages referral to specialists and the prescription of costly medications. Primary care physicians therefore are incentivized to

refer families to emergency departments, which may be contributing to the increased visits to emergency departments by island Puerto Ricans.